Diary

Replacing Obamacare - The Necessary Republican Plan

Few would deny that the passage and ugly implementation of Obamacare was the signature achievement of Barack Obama and Nancy Pelosi’s time in power. Few would also deny that the failure to repeal and replace Obamacare is, thus far, the signature failure of Donald Trump, Mitch McConnell, and Paul Ryan. But that is not the end of the story – nobody except the pharmaceutical companies likes the current set-up with its soaring costs and spotty insurance coverage. Bernie Sanders has started the call for “Medicare for all”; the left wing loons in California are calling for a $400 billion state run program; conservative states which did not accept Medicaid expansion under Obama are left out from the federal trough under Trump; everybody on the Right agreed with the “Repeal” part of “Repeal and Replace.” This is not the end of the national discussion.  How and when it resumes is up to the Republican leadership which has great risk, but also great opportunity.

The greatest mind-numbing, political malpractice disappointment of a generatioin is that after seven years of complaining and sloganeering, the Republican Congress did not have a replacement ready for a Republican president’s signature. Maybe they didn’t believe that they would actually have a Republican president. Maybe getting together would have bruised too many egos. Maybe agreeing on general principles and filling in the tactical details was beyond the capabilities of the leaders. Maybe things are more difficult than in the old days when earmarks could be used to buy votes. Maybe Trump is too big a negative. Whatever, that was then. If the Republicans do not present a conservative alternative before the 2020 election, the lure of a simple alternative from the Left will be unstoppable, and the Republicans will have earned their demise.

The premise:

– In 2018 the Republicans will marginally increase their majority in the Senate under almost any circumstance, with the Democrats defending 23 seats and the Republicans 10. In the House the marginal likelihood of giving up the 24 seats necessary to give the chamber back to Nancy Pelosi would be much less if there were a Republican healthcare plan.

– On the substance, it is good that the efforts to slap together a Senate version did not succeed. There is now time to put together a proposition which works, based on conservative principles.

The process:

– Take a deep breath.

– Organize a small team of White House, Senate, and House leaders to devise the plan. Draw on the experience of the past six months to define what is possible. Forget the Democrats – unless Joe Manchin or Angus King will change parties.

–  Start discussions in the House and Senate from the same simple blueprint.

–  Politics is the art of the possible. Forget ideology. Fire McConnell or Ryan if they cannot design a proposal based on conservative principles that can pass their chamber.

–  Ideally, have it done by early 2018. If not, use the outline as a campaign theme, implementing in 2019.

– Hire a good public relations agency.

And the content:

– First, it is important to recognize what is not on the table: we generally do not have state-run hospitals; doctors do not work for the government; individuals can have supplemental insurance plans; we use co-pays and deductibles to minimize frivilous use of the system; we do not have price controls; the government generally does not cover vision, dental, or long term care. (Progressives would love much of this, and inserted many elements in their bill which recently passed the California senate.)

– There are several easily-agreed (at least among conservatives) components: allowing insurance companies to sell “bare bones” catastrophic coverage policies; selling insurance across state lines; subsidized high risk pools; greater transparency in hospital pricing; allowing the states to design elements of their own programs as in Medicaid.

– Beyond insurance, there are a number of ways to reduce overall costs: constraints on medical malpractice lawsuits; greater use of clinics and nurse practitioners; faster FDA approval of generics; shortened periods for patent protection.

Things like stock market bubbles that cannot go on forever frequently end badly. But not always – sometimes there are wise and prudent central bankers, legislative leaders, and executives who understand the levers to pull to safely deflate the bubble. That opportunity is at hand for Obamacare. The need to replace Obamacare is understood. The alternatives are known. The politics have been deeply and painfully plumbed. It is not much of a stretch to say that if the Republican leaders cannot present the plan well before the 2018 election, they deserve to be replaced.

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www.RightinSanFrancisco.com – 8/18/2017